title: Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study.
abstract: OBJECTIVE
  The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality.
  
  
  METHODS
  We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs.
  
  
  RESULTS
  From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality.
  
  
  CONCLUSIONS
  In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada.
authors.forename: Paul D
authors.initials: PD
authors.lastname: James
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Gilaad G
authors.initials: GG
authors.lastname: Kaplan
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Myers
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Hubbard
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Abdel Aziz
authors.initials: AA
authors.lastname: Shaheen
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jill
authors.initials: J
authors.lastname: Tinmouth
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Elaine
authors.initials: E
authors.lastname: Yong
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Love
authors.affiliation: Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Calgary Research and Education in Advanced Therapeutic Endoscopy, Calgary, Alberta, Canada. Electronic address: steven.heitman@ucalgary.ca.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Heitman
mesh_terms: D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002761:Cholangitis / Q000175:diagnosis* / Q000401:mortality*; D042883:Choledocholithiasis / Q000175:diagnosis* / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis* / Q000401:mortality*; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology
keywords: Cohort Study; Death; ERCP; Outcomes